
			<div id="header_text">
				
			</div>
			<div id="body_text">
			<fieldset>
				<legend>Please provide the information requested below.</legend>
					<form name="signup" id="signup" action="/register.php" method="post" onsubmit="return validate_form(this)">
						<ul>
							<li> <label for="firstname">First Name</label>
								<input type="text" name="firstname" id="firstname" size="30" tabindex="1" />
							</li>
							<li> <label for="email">Email Address</label>
								<input type="text" name="email" id="email" size="30" tabindex="3" />
							</li>

							<li> <label for="state">State</label>
								<input type="text" name="state" id="state" size="30" tabindex="5" />
							</li>
						</ul>
						<ul id="checkboxes">	


							<li id="actions">
							<label for="reset"></label>
								<input type="reset" id="reset" value="reset" tabindex="11" />
							
							<label for="submit"></label>
								<input type="submit" id="submit" value="submit" tabindex="10" />
							</li>
						</ul>
						<ul id="right_form">
							<li> <label for="lastname">Last Name</label>
								<input type="text" name="lastname" id="lastname" size="30" tabindex="2" />
							</li>
							<li> <label for="city">City</label>
								<input type="text" name="city" id="city" size="30" tabindex="4" />
							</li>

							<li> <label for="zip">Zip Code</label>
								<input type="text" name="zip" id="zip" size="30" tabindex="6" />
							</li>
						</ul>
						<p>*If you are under 18 years of age, you must have your parents’ permission to enroll. <a href="pop.php?page=parental-approval" onclick="newWindow(this.href); return false;">Click here to provide parental approval. </a></p>
					</form>
			</fieldset>
	
				
			</div><!-- end body text -->